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The increased use of antidepressants has contributed to the worldwide reduction in suicide rates

  • Göran Isacsson (a1), Charles L. Rich (a2), Jon Jureidini (a3) and Melissa Raven (a4)

Numerous ecological studies have shown an inverse association between antidepressant use and suicide rates and a smaller number of individual-based studies have shown an association between current antidepressant use and reduced suicide risk. Such evidence is often cited in support of the notion that antidepressants prevent suicide. However, more recently, the premises underlying this proposition, namely that suicide is caused by depression and that antidepressants relieve depression, have been challenged and the potential harm caused by antidepressants has been highlighted. In this article, Goran Isacsson and Charles Rich debate with Jon Jureidini and Melissa Raven the motion that the increased use of antidepressants has contributed to the worldwide reduction in suicide rates.

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The increased use of antidepressants has contributed to the worldwide reduction in suicide rates

  • Göran Isacsson (a1), Charles L. Rich (a2), Jon Jureidini (a3) and Melissa Raven (a4)
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Ecological studies and data linkage studies in suicide research

Melissa Raven, Adjunct lecturer
14 July 2010

We welcome Riordan and Stark's suggestion that declining family size may have contributed to declining suicide rates. I agree. As we noted, there are many potential confounding variables in the relationship betweenantidepressant use and suicide.

Riordan and Stark cite two birth cohort studies using data linkage that both found that birth order was independently associated with suiciderisk. In Riordan et al.'s 2006 analysis of linked data from the Scottish Morbidity Record and Scottish death records, higher maternal parity, younger maternal age, non-professional parental occupations, and low birthweight were all independently associated with higher suicide risk of offspring in young adulthood.1 In Gravseth et al.'s study using several Norwegian national registers, suicide risk factors included higher maternal parity, instability of maternal marital status during childhood, low education levels, and severe mental illness.2 Notably, maternal parityremained a significant risk factor even after adjustment for mental illness.

Data linkage studies such as Riordan et al.'s and Gravseth et al.'s are particularly important in suicide research because of the need for adequately large sample sizes and sufficient statistical power to investigate suicide, a relatively rare event. They are methodologically superior to ecological studies, which are the mainstay of claims that antidepressants reduce suicide. The inherently weak methodology of ecological studies is often compounded by failure to control for potentialconfounding factors and by biased interpretation.3,4

Data linkage studies generally reveal multiple significant contributory factors, many of which are linked to social adversity. Furthermore, many such factors also contribute to other forms of prematuremortality, such as accidental death and natural death due to preventable conditions. For example, Riordan et al. also found an association between higher maternal parity and increased risk of offspring death from causes other than suicide. The aetiological overlap means that primary preventionfocusing on shared determinants has greater potential to reduce overall mortality.5

Data linkage studies provide valuable evidence that challenges the simplistic belief that depression is the cause of suicide and antidepressants are the solution. As emphasised by De Leo & Cerin,4 suicide is not simply a function of depression, and suicide prevention is far more than a psychiatric enterprise.

Declaration of interest

I am a member of Healthy Skepticism.


1 Riordan DV, Selvaraj S, Stark C, Gilbert JS. Perinatal circumstances and risk of offspring suicide. Birth cohort study. Br J Psychiatry. 2006 Dec; 189: 502-7.

2 Gravseth HM, Mehlum L, Bjerkedal T, Kristensen P. Suicide in young Norwegians in a life course perspective: population-based cohort study. J.Epidemiol Community Health. 2010 May; 64(5): 407-12.

3 Safer DJ, Zito JM. Do antidepressants reduce suicide rates? Public Health. 2007 Apr; 121(4): 274-7.

4 De Leo D, Cerin, E. More than antidepressants are needed to avert suicide. BMJ. 2003 May 15. (

5 Neeleman J. A continuum of premature death. Meta-analysis of competing mortality in the psychosocially vulnerable. Int J Epidemiol. 2001 Feb; 30(1): 154-62.
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Conflict of interest: None Declared

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Interpretation of Ecological Data

Daniel Vincent Riordan, Consultant Psychiatrist; Honorary Clinical Senior Lecturer
28 June 2010

We read the debate on antidepressants and suicide(1) with interest, especially the issue concerning the importance of controlling for possibleconfounding variables in ecological studies, and the associated difficulties in drawing conclusions from such ecological observations.

One potentially important confounder in this instance, which has beenoverlooked, may be the size of the family of origin.

Birth cohort studies from Scotland(2) and Norway(3) suggest that having elder siblings may be linked with increased risk of suicide. As thetotal fertility rates (a reasonable proxy for average family size) fell across most western countries between the 1950s and 1970s(4), it is plausible that some of the decline in suicide rates observed from the late1980s onwards may be, in part at least, a resultant cohort effect.

1.Isacsson G, Rich CL, Jureidini J, Raven M. The increased use of antidepressants has contributed to the worldwide reduction in suicide rates. Br J Psychiatry 2010; 196; 429-433

2.Riordan DV, Selvaraj S, Stark C, Gilbert JE. Perinatal Circumstances and Risk of Offspring Suicide in a Scottish Birth Cohort. BrJ Psychiatry 2006; 189: 502-507.

3.Gravseth HM, Mehlum L, Bjerkedal T, Kristensen P. Suicide in youngNorwegians in a life course perspective: population based cohort study. J.Epidemiol. Community Health 2010; 64: 407 – 412.

4.Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The2008 Revision,
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Conflict of interest: None Declared

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